Published: Oct. 17, 2006
Updated: Nov. 8, 2010
Got a niggling ache or twinge in your back, your elbow, your neck? Key a few words describing your symptoms into an online search engine and you’ll immediately plug in to a world of hurt.
Countless electronic bulletin boards overflow with messages from people who have been suffering from persistent pain for months or even years, begging for any shred of worthwhile advice. Often they don’t get much more for their troubles than words of sympathy from fellow sufferers.
We all have transient aches and pains caused by injury or illness. Sometimes, however, pain continues long after the condition that caused it has resolved. Sometimes, no particular reason for chronic pain can be identified at all. It can occur anywhere in your body and range from a mild annoyance to near-agony that wrecks your mood and wreaks havoc on your ability to function.
Technically defined as any pain that lasts for three months or longer, chronic pain is a puzzle. It may be due to signals that, once triggered by the nervous system, continue to fire for months or even years. Some theories also suggest that pain-dampening chemicals manufactured within the brain don’t work properly in chronic pain sufferers.
What’s clear about chronic pain is the huge scale of the problem. The World Health Organization (WHO) recently published results of a survey of 25,916 primary care patients in 14 different countries. More than 20 percent of them had experienced persistent pain for at least half of the previous year.
People who had chronic pain were more likely be anxious or depressed, had a negative outlook about their health, and had trouble concentrating on and completing their work. In the United States, persistent pain accounts for some 515 million lost work days and about 40 million doctor’s visits each year.
By its very nature, pain is highly subjective: A level of pain that’s acceptable for one person might be intolerable to another. A doctor can help determine an individual’s tolerance for pain with the use of a pain intensity scale. For instance, if a patient rates his pain as 6 out of 10 on average and then decides he can tolerate 3 out of 10, he and his doctor have a tangible goal to work toward. They may not be able to get the pain level down to a zero, but usually they can make progress.
Americans spend more than $6 billion in pain medications every year, half of it on over-the-counter analgesics such as acetaminophen and ibuprofen. But they’re not always effective -- and can, over time, cause stomach bleeding, ulcers, liver damage, and other problems.
According to Tong-Joo (TJ) Gan, MD, medical director of Duke’s perianesthesia care unit, a newer class of drugs, COX-2 specific inhibitors, work like NSAIDs (non-steroidal anti-inflammatory drugs, such as ibuprofen) but have fewer side effects. “These drugs are especially effective on diseases characterized by persistent pain, such as rheumatoid arthritis and osteoarthritis,” Gan says, adding that they’re also widely used after surgery.
For severe pain, heavy-duty drugs are sometimes necessary. While the use of opiates such as morphine is well established in pain, Duke is using an innovative strategy that combines these powerful substances with small doses of opiate antagonists, which chemically counter their effects.
The technique not only reduces side effects such as nausea, vomiting, and constipation, but -- surprisingly -- enhances the medication’s analgesic power. Gan has also found the experimental use of anti-seizure drugs in pain management to be highly promising, especially for long-term, repetitive-use pain syndromes.
Nevertheless, Gan says, “The most effective way to treat pain is not just by a pill or two, but a multi-modal strategy that incorporates exercise, physical therapy, and an integrated approach to the mind-body connection. Lifestyle changes that involve the entire family see the most success.”
Veeraindar Goli, MD, former medical director of the Pain Evaluation and Treatment Services, agrees. “Pain is the second most common reason why an individual sees a physician, and it benefits from a collaborative approach,” he says. “We provide patients with a complete assessment and offer treatment options tailored to their needs, which may include medications, Botox injections, acupuncture, cognitive behavior therapy, biofeedback, or referral to a surgeon.
"We are also very fortunate to have access to the Anesthesiology Pain Clinic, Neurological Disorders Clinic, Biofeedback Laboratory and other resources at the Duke Health Center at Morreene Road, where we all work collaboratively under the same roof," he adds. "Winston Parris, MD, the new director of the Anesthesiology Pain Clinic, brings additional resources and international recognition to an already talented group whose interventional skills and techniques are second to none."
Chronic pain commonly occurs in older adults or others with health conditions. Nearly one in five Americans over age 60 regularly takes medication for chronic pain, according to a survey conducted for the National Council on the Aging. However, pain is not a normal part of aging, and treatment should be sought.
“Chronic pain is an overwhelming experience -- you get really depressed and feel as if no one in the world can help you,” says Margaret D., a 63-year-old Duke Pain Clinic patient who suffers from disabling arthritis, fibromyalgia, and back pain. “But Dr. Goli really listened to me, talked to me so empathetically, and laid out my options so clearly, that I began to feel as if I had some control over my situation.”
“The patient is an important member of the treatment team,” says Goli. “It’s important that our patients feel validated and empowered by the process of care. Then, even if it takes a while to find the right combination of strategies, they feel more optimistic, they cope better, and they begin to experience a better quality of life.”
Children, too, have persistent pain -- and often suffer needlessly because they lack the verbal skills to describe their discomfort. According to Laura Schanberg, MD, director of Duke’s Pediatric Pain Clinic, “That means that physicians taking care of youngsters in pain must rely less on verbal cues and more on observation and physical evaluation.”
Clinic patient Taylor B. is one of the pediatric clinic’s many success stories. The 11-year-old with sky-blue eyes was in constant pain from irritable bowel syndrome (IBS) from the time she was seven years old. But, through biofeedback, diet modification, meditation, and a small amount of medication, she can now enjoy activities such as playing and eating pizza. “She feels so much more in control of her life,” says her grateful mom.
“No one modality helps individuals with chronic pain -- there’s no magic bullet,” Goli concludes. “Nevertheless, people in chronic pain should never hesitate to seek help. We have many tools in our toolbox to deal with this disabling condition.”